Manhattan Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Mississippi.
- Location
- 4540 Manhattan Rd, Jackson, Mississippi 39206
- CMS Provider Number
- 255115
- Inspections on file
- 26
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Manhattan Community Care Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse prevention policy by not removing a CNA from resident care after multiple abuse allegations, and did not conduct a timely or thorough investigation. Two residents with significant medical and cognitive needs reported rough and intimidating treatment by the CNA, but the CNA continued to provide care to them. Nursing staff acknowledged the complaints but did not ensure the CNA was reassigned, and family members were not updated on the investigation.
A resident with dementia and a history of exit-seeking behaviors was assisted outside by staff without proper identification or supervision, resulting in the resident being unsupervised outdoors for an extended period and later found lying on the ground near the facility's perimeter. The staff member responsible had not verified the resident's identity or risk status, and the incident was not immediately recognized by the assigned unit manager, leading to a lapse in required supervision and security.
A resident with a non-pressure ulcer did not receive wound care as ordered by the physician, with a scheduled treatment missed and not documented. Staff interviews revealed confusion regarding the wound care schedule, and the dressing change was not properly signed, dated, or timed. The DON and Administrator confirmed the lapse in care.
A resident with severe cognitive impairment and a care plan requiring one-on-one supervision was left unsupervised, resulting in a fall and a fracture. The resident exhibited agitation during a therapy session, but the speech therapist did not inform the nursing staff, assuming they were monitoring the resident. The assigned CNA was late, and no other staff was designated to supervise, leading to the resident's injury.
A resident with dementia and behavioral disturbances fell and sustained a fracture due to a lapse in supervision at an LTC facility. The resident was supposed to be under continuous one-on-one supervision, but the assigned CNA arrived late, leaving the resident unsupervised. The resident was agitated and attempted to stand during a therapy session, and later fell in the dayroom, resulting in hospitalization.
Two residents in the facility reported deficiencies in accommodating their preferences for hydration and personal care. One resident, with severe cognitive impairment, preferred daily shaving and bedside water, but these preferences were not met, leading to delays and the resident's representative having to assist with shaving. Another resident, who is cognitively intact, also experienced delays in receiving water and preferred having it readily available at the bedside. The acting Administrator acknowledged the expectation to accommodate resident preferences.
A facility failed to respect a resident's food preferences, leading to a deficiency. Despite the resident's clear dislike for oatmeal and her cognitive ability to communicate this, she continued to receive it on her breakfast tray multiple times weekly. The facility's policy required that food preferences be recorded and utilized, but this was not followed. The dietician and acting Administrator were aware of the issue, yet the resident's preferences were not accommodated.
A facility failed to maintain sanitary practices in food service when a Registered Dietitian (RD) was observed picking up an ink pen from the floor and handling food service items without washing her hands. The RD also licked her fingers while flipping through meal cards. Interviews with the RD, Dietary Manager (DM), and Assistant Administrator (AA) confirmed these actions, despite annual infection control training.
The facility was found to have unlocked biohazard rooms on two survey days, with open biohazard cans and chemical dispensers inside. The Housekeeping Supervisor and ANHA acknowledged the need for these doors to be locked to ensure safety.
The facility failed to implement comprehensive care plans for several residents, leading to unmet needs. A resident requiring adaptive utensils for self-feeding was not consistently provided with them, while others lacked engagement in scheduled activities. Additionally, a resident's comprehensive care plan was overdue, and another's skin care interventions were not followed. Staff interviews confirmed these deficiencies.
A CNA improperly applied zinc oxide cream, considered a medication, to a resident's buttocks and perineal area, contrary to facility policy which mandates that only licensed personnel administer medications. The CNA was unaware that zinc oxide was a medication and applied it after each incontinent episode, as observed by surveyors. The DON confirmed the policy breach, stating CNAs should only use barrier cream.
The facility failed to provide adequate activities for residents, particularly on the upper floors, leading to a lack of engagement and dissatisfaction among residents. Observations showed residents were often left without activities, despite scheduled events on the activity calendar. Staff and resident interviews confirmed that activities were primarily conducted on lower floors, leaving some residents without appropriate engagement.
A resident with an indwelling suprapubic catheter was observed with catheter tubing dragging on the floor, posing an infection control issue. The tubing's contact with the floor was confirmed by an LPN and acknowledged by the DON and Assistant Executive Director as a significant infection risk. The resident had a history of HIV and Neuromuscular Dysfunction of the Bladder.
A facility failed to provide a palatable meal during a lunch observation, as a resident and the Dietary Manager noted the macaroni and cheese was bland and lacked flavor. The resident, who is on a Regular, NAS diet with diabetes precautions, expressed that the food often lacked taste. The facility's policy requires meals to be nourishing and palatable, which was not met in this instance.
A resident with a hand disability was not consistently provided with a built-up fork, as required by their care plan, leading to challenges during meals. Despite the facility's policy and the resident's repeated requests, the necessary utensil was often missing from meal trays. Staff acknowledged the shortage of built-up forks and had placed an order, but delays contributed to the ongoing issue.
The facility failed to ensure call light accessibility for two residents, impacting their ability to request assistance. One resident with Hemiplegia and Cerebellar Stroke Syndrome was unable to reach the call light placed behind her, while another resident with Major Depressive Disorder and Osteoarthritis had the call light hung out of reach. The DON and Administrator acknowledged the importance of call light accessibility, although no specific policy was in place.
The facility failed to implement comprehensive care plans for two residents, resulting in deficiencies in care. One resident's call light was out of reach, preventing assistance with urinary incontinence and fall prevention. Another resident's call light was also out of reach, and their bed was left elevated, contrary to care plan instructions. Staff confirmed the importance of following care plans to meet residents' needs.
A resident with incontinence did not receive timely and proper incontinence care, as required by facility policy. The resident was left without care for several hours, and when care was provided, a CNA used improper techniques by wiping back to front with the same cloth, increasing the risk of infection. Despite in-service training, the facility's documentation did not accurately reflect the timing of care provided.
Failure to Remove CNA and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse prevention policy by not removing a Certified Nursing Assistant (CNA) from resident care following multiple allegations of potential abuse. Despite reports from residents and their family members that the CNA was rough, mean, and had allegedly hit or intimidated a resident, the CNA continued to provide care to the same residents. Interviews revealed that both residents and their representatives reported these concerns to nursing staff, but the CNA was not removed from their assignments, and continued to enter the rooms of the affected residents. The investigation into the allegations was neither timely nor complete. Family members and residents reported that after making complaints to the nursing staff, there was no follow-up or communication from the facility regarding the status of the investigation or any actions taken. The LPN Charge Nurse acknowledged her responsibility to remove the CNA from resident care during an allegation of abuse, but confirmed that the CNA continued to have contact with the residents involved. The Director of Nursing (DON) also indicated that the situation should have been addressed more thoroughly, especially since multiple residents had raised concerns about the same CNA. The residents involved had significant medical conditions and cognitive impairments, as indicated by their diagnoses and Brief Interview Mental Scores (BIMS). One resident expressed fear and distress due to the CNA's continued presence, stating she could not sleep while the CNA was in the room. Documentation and interviews confirmed that the facility did not implement interventions to protect residents from further potential abuse, nor did it ensure proper reporting and investigation procedures were followed as outlined in its abuse prevention policy.
Failure to Prevent Elopement Due to Inadequate Supervision and Staff Error
Penalty
Summary
A newly admitted respite resident with diagnoses of restlessness, agitation, dementia, senile degeneration of the brain, and a history of exit-seeking behaviors and falls was assisted to exit the facility by staff. The resident was outside unsupervised for approximately twenty-five minutes until a staff member observed her lying on the ground next to the iron fence that encircled the facility premises, about 375 feet from the facility entrance. The resident had been admitted earlier that day and was only oriented to self, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The facility's policy required staff to know the location of their residents and to report or intervene if a resident attempted to leave the premises. However, the receptionist, who was not aware of the new admission and had not verified the resident's identity, unlocked the door and escorted the resident outside without determining if she was safe to exit. The resident then wandered the grounds unsupervised, eventually being found by staff who were leaving their shift. The staff who found her did not initially recognize her as a resident and had to ask questions to confirm her status before summoning the DON and assisting her back into the facility. Interviews and record reviews confirmed that the receptionist had received training on security and elopement risks but failed to follow procedures. The incident was not immediately recognized by the assigned unit manager, who had assessed the resident as not at risk for elopement based on incomplete information. The resident's responsible party and primary healthcare provider were notified after the incident, and the resident was not injured. The facility's failure to provide adequate supervision and a secure environment contributed to the resident's elopement and placed all residents with wandering or exit-seeking behaviors at risk.
Removal Plan
- A second at risk for elopement assessment completed for Resident #9
- Resident #9's Instant care plan and Kardex were updated
- One-on-one supervision orders received, and monitoring implemented
- Resident #9's Responsible Party (RP) and Primary Healthcare Provider were notified of the incident with safe wandering device bracelet orders received with bracelet applied on Resident #9 with orders for nurses to check placement and functioning every shift
- Head to toe body audit was conducted for Resident #9
- Nursing staff completed 100% head count of all residents not signed out on pass with all residents accounted for
- Employee corrective counseling completed with former Receptionist (Category 1 offence, employment terminated)
- 100% At risk for elopement evaluations completed on all residents
- 100% in-service training started for all staff prior to working on - Elopement/Wandering, Abuse/Neglect, Behaviors, Adequate monitoring, Supervision
- Safe wandering devices for all residents wearing them are checked every shift for placement and functioning
- Elopement Drills were conducted on all shifts
- 100% audit of elopement books completed
- All doors checked for proper functioning
- Security specialist contractor visited and checked doors for functioning
- Quality Assurance (QA) Meeting attended by all key personnel, which included but not limited to Executive Director, Director of Nurses, Infection Preventionist and Medical Director was held with root cause analysis conducted and interdisciplinary team developed strategy to prevent future elopement incidents
- Resident #9 to remain on 1:1 until discharge from facility; discharged
- Resident photos will be taken at the time of admission, regardless of elopement risk assessment results, and posted at the receptionist desk
- One-on-one monitoring/supervision of Resident #9 through discharge
- Admissions Coordinator to monitor the communication board in the reception office to ensure the board's accuracy and currently with all new admissions' photographs posted
- Continued elopement assessments of all newly admitted residents at the time of admission by nursing staff
- Continued monitoring of positioning and functioning of safe wandering devices worn by residents at risk of elopement every shift by nursing staff
- Continued daily monitoring of the safe wandering system functionality by the maintenance director
- Review of and development of care plans for all newly admitted residents with family/resident to evaluate for history of wandering/elopement for three (3) months with monitoring results and corrective actions reviewed at QA meetings for three (3) months
Failure to Provide Wound Care per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide wound care in accordance with physician orders and facility policy for one resident with a non-pressure ulcer. The resident had a physician order for wound care to be performed every three days, including cleaning the wound with normal saline, applying Mupirocin ointment, and covering with Mepilex. Documentation showed that wound care was completed on one scheduled date but was not documented or performed on the next scheduled date, as evidenced by the absence of staff initials in the treatment record. The resident reported that the wound care was not performed as ordered and that the wound was not irrigated as specified in the physician's instructions. Interviews with staff revealed a lack of awareness and adherence to the wound care schedule. The LPN/unit manager stated that a PRN order had been obtained and that she provided the dressing change a day after it was missed, but the dressing was not signed, dated, or timed as required. Another LPN was unaware of why the wound care was missed, and the DON and Administrator acknowledged that the care had not been completed as ordered. The resident had a history of diabetes, a non-pressure chronic ulcer, and vascular dementia, with intact cognition at the time of the incident.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement a care plan intervention for a severely cognitively impaired resident, resulting in an unsupervised fall and an acute transverse fracture of the lower sacrum. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and osteoarthritis, had a comprehensive care plan requiring one-on-one supervision when family was not present. On the day of the incident, the resident was left unsupervised in the dayroom after a therapy session, despite exhibiting agitation and attempts to stand up. The speech therapist, who had been working with the resident, did not notify the nursing staff of the resident's behavior before leaving, assuming they were observing him through a window. The Director of Nursing acknowledged that the resident was supposed to have one-on-one supervision, but the assigned CNA was late, and no other staff was designated to monitor the resident. Consequently, the resident was found sitting on the floor in the dayroom, having fallen and later diagnosed with a fracture. Interviews with staff, including the DON and MDS Coordinator, highlighted the importance of following the care plan to ensure resident safety, which was not adhered to in this case, leading to the resident's injury.
Lapse in Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in a fall and injury to a resident. The resident, who had been admitted with dementia and behavioral disturbances, was supposed to be under continuous one-on-one supervision due to increased agitation. However, there was a lapse in supervision when the assigned CNA did not arrive on time, and no other staff member was present to supervise the resident. On the day of the incident, the resident was observed to be agitated and attempting to stand up during a therapy session. The therapist redirected the resident but did not inform other staff of the resident's behavior, assuming they were being monitored. After the therapy session, the resident was left unsupervised in the dayroom, where they eventually fell and sustained a fracture. Interviews with staff revealed that there was a miscommunication regarding the supervision assignment. The CNA who was supposed to provide one-on-one supervision arrived late, and the LPN on duty was unaware that the resident was left unsupervised. The Director of Nursing confirmed that there was a lapse in supervision, which led to the resident's fall and subsequent hospitalization.
Failure to Accommodate Resident Preferences for Hydration and Personal Care
Penalty
Summary
The facility failed to accommodate resident preferences for two residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident #4, who has severe cognitive impairment due to Parkinson's Disease and Alzheimer's Disease, expressed a preference for having water available at the bedside and being shaved daily. However, the facility only provided water upon request, causing delays, and did not accommodate the resident's preference for daily shaving, leaving the resident's representative to sometimes perform the task during visits. Similarly, Resident #3, who is cognitively intact and has diagnoses including Congestive Heart Failure, Type 2 Diabetes Mellitus, and Hypertension, also reported not having water readily available at the bedside. The resident stated that requests for water often resulted in waiting periods, and she preferred to have a water pitcher, glass, or bottle at her bedside. The acting Administrator confirmed that staff are expected to accommodate resident preferences, but this was not achieved in these cases.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide a diet according to a resident's preferences, resulting in a deficiency. A resident, who was admitted with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus, expressed dissatisfaction with receiving oatmeal on her breakfast tray multiple times weekly, despite her dislike for it. The resident, who was cognitively intact with a BIMS score of 15, had communicated her food preferences to the staff multiple times. The facility's policy required that resident food preferences be recorded and consistently utilized, but this was not adhered to in the case of this resident. The facility's dietician acknowledged awareness of the resident's complaints about oatmeal and had emphasized the importance of accommodating food preferences to the dietary staff and cooks. The acting Administrator also confirmed the expectation that dietary staff should accommodate resident food preferences whenever possible. Despite these acknowledgments, the resident continued to receive oatmeal, indicating a failure in the facility's processes to ensure dietary preferences were respected.
Failure to Maintain Sanitary Practices in Food Service
Penalty
Summary
The facility failed to maintain sanitary practices in accordance with professional standards for food service safety, specifically related to hand hygiene. During an observation, a Registered Dietitian (RD) was seen picking up an ink pen from the kitchen floor and placing it back on the steam table. Subsequently, the RD handled a food service utensil, a food thermometer, and a menu book without washing her hands. Additionally, the RD was observed licking her fingers while flipping through residents' meal cards, which were to be placed on each tray. Interviews with the RD, Dietary Manager (DM), and Assistant Administrator (AA) confirmed these observations. The RD acknowledged the actions and admitted that she would not want her food contaminated in such a manner. The DM confirmed witnessing the RD's actions and stated that staff were expected to use hand hygiene in the kitchen, with annual training provided on infection control. The AA also acknowledged the incidents and emphasized the expectation for staff to follow safety protocols and use hand hygiene after touching contaminated surfaces.
Unlocked Biohazard Rooms Compromise Safety
Penalty
Summary
The facility failed to provide a safe environment for residents, as evidenced by unlocked biohazard rooms on two of the four days of the survey. On 07/22/24, an observation revealed an unlocked door marked 'Biohazard' on the second floor, with an open red biohazard can and visible red biohazard bags inside. Additionally, housekeeping chemical dispensers containing Vindicator, a disinfectant with health hazards for acute oral toxicity and skin corrosion/irritation, and Super Shine All, a floor cleaner with health hazards for serious eye damage/eye irritation, were present. On 07/23/24, during an observation and interview, the Housekeeping and Laundry Supervisor confirmed the biohazard room door was not secured and stated that such doors should always be closed and locked to ensure safety. The Assistant Nursing Home Administrator acknowledged the requirement for biohazard room doors to be closed and locked, emphasizing the responsibility of all employees to secure these doors to prevent exposure to medical waste or chemicals.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six of the thirty sampled residents, leading to deficiencies in meeting the residents' needs. For Resident #53, the care plan indicated the need for adaptive equipment, specifically built-up utensils for self-feeding due to a hand disability. However, observations revealed that the resident was not consistently provided with the necessary utensils, forcing him to eat with his hands. Despite repeated requests to the kitchen staff and CNAs, the resident often did not receive the appropriate fork, highlighting a failure in adhering to the care plan. Resident #57's care plan required staff to remind and encourage participation in group activities, but observations showed a lack of individualized activities and engagement for residents on the third floor, including Resident #57. Similarly, Resident #121 and Resident #122, who also resided on the third floor, were not provided with appropriate activities as outlined in their care plans. The facility's activity calendar indicated scheduled activities, but none were observed during the survey period, indicating a failure to implement the care plans effectively. Resident #68's care plan was incomplete, as the comprehensive care plan had not been developed despite the resident's admission date being well past the timeframe for completion. Additionally, Resident #80's care plan required specific skin care interventions, but there was a lack of adherence to the care plan regarding the application of zinc oxide for skin impairments. Interviews with facility staff, including the LPN, RN, AED, and DON, confirmed the deficiencies in care plan implementation and the importance of following care plans to ensure appropriate care for residents.
Improper Medication Administration by CNA
Penalty
Summary
The facility failed to adhere to professional standards by allowing a Certified Nursing Assistant (CNA) to apply a medicated cream, zinc oxide, to a resident's buttocks and perineal area, which is against the facility's policy. The policy specifies that medications should only be administered by licensed personnel. The incident involved a resident who was alert and oriented, and who reported discomfort in her buttocks. The CNA applied the zinc oxide cream after each incontinent episode, believing it was a barrier cream, not realizing it was considered a medication. The deficiency was observed during a survey when a jar of zinc oxide was found on the resident's bedside table. The CNA confirmed applying the cream, stating she was instructed to do so after every incontinent episode. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged that the CNAs were not authorized to apply zinc oxide, which should only be applied by licensed nurses. The DON admitted to being unaware that CNAs were using zinc oxide instead of the barrier cream provided by the facility.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities of interest to meet the needs of three residents, as observed during a survey. Resident #57, who had severe cognitive impairment, was frequently found sleeping in a Geri chair or in the hallway with no activities provided, despite the activity calendar indicating scheduled events like Bingo and Coffee. The resident expressed that there was nothing to do, and staff confirmed that activities were primarily conducted on the lower floors, leaving residents like #57 without engagement. Resident #121, with severe cognitive impairment, was observed talking to a baby doll and ambulating the hallways without any individualized activities. The resident's MDS indicated a preference for music, group activities, and outings, none of which were provided. Observations showed the resident was often left without appropriate engagement, contributing to a lack of stimulation and potential behavioral issues. Resident #122, who was cognitively intact, expressed dissatisfaction with the lack of activities and the inability to go outside. The resident was observed wandering the hallways and was difficult to redirect, as confirmed by staff. The activity calendar listed various activities that were not conducted, and interviews with staff and the Resident Council President revealed systemic issues with staffing and scheduling, leading to insufficient activity provision on the upper floors.
Failure to Prevent Infection Control Issue with Catheter Tubing
Penalty
Summary
The facility failed to prevent potential complications related to a resident with an indwelling suprapubic catheter. During an observation, it was noted that the catheter tubing of Resident #117 was dragging on the floor as the resident moved through the dining room and hallway in a wheelchair. This observation was confirmed by a Licensed Practical Nurse (LPN) who acknowledged that the tubing's contact with the floor posed an infection control issue. The resident had a physician's order for a 16F 10cc suprapubic Foley catheter with a closed urinary drainage bag system, dated April 3, 2024. Interviews with the Director of Nursing (DON) and the Assistant Executive Director further confirmed the deficiency. Both acknowledged that indwelling catheters could be a significant cause of infection, and it was the responsibility of the nursing staff to ensure catheter tubing was not in contact with the floor. The resident, admitted on October 20, 2023, had diagnoses including Human Immunodeficiency Virus (HIV) disease and Neuromuscular Dysfunction of the Bladder, and the Quarterly Minimum Data Set (MDS) assessment dated June 28, 2024, confirmed the presence of an indwelling catheter.
Deficiency in Meal Palatability
Penalty
Summary
The facility failed to provide a palatable meal during a lunch observation, as evidenced by the State Agency (SA) and the Dietary Manager (DM) sampling a lunch tray that included macaroni and cheese, which was found to be bland and lacking cheese flavor. This observation was corroborated by Resident #14, who expressed that the food often lacked taste, specifically noting the tastelessness of the macaroni and cheese served at lunch. The facility's policy on Menu Planning and Requirements, dated 2016, mandates that meals should be nourishing, palatable, and attractive, which was not adhered to in this instance. Resident #14, who was admitted to the facility on 11/22/23, has a diagnosis of Type 2 Diabetes Mellitus and is on a Regular, No Added Salt (NAS) diet with diabetes precautions. The resident's cognitive status is intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 on the Quarterly Minimum Data Set (MDS) assessment dated 05/03/24. The Assistant Executive Director (AED) emphasized the expectation for the Dietary Manager to prepare flavorful and safe meals, highlighting a discrepancy between expectations and the observed meal quality.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to consistently provide adaptive eating equipment to a resident who required it due to a hand disability. The resident, who was cognitively intact and diagnosed with paraplegia, needed a built-up fork to eat independently. Despite the facility's policy stating that adaptive devices should be available to residents at mealtime according to their individualized plan of care, the resident frequently did not receive the necessary utensil. Observations during mealtime confirmed that the resident's tray often lacked the built-up fork, forcing him to eat with his hands, which he found challenging and frustrating. Interviews with the resident, dietary staff, and a CNA revealed that the issue was ongoing and known to the staff. The Dietary Manager and Assistant Administrator acknowledged that the facility was running low on built-up forks and had placed an order for more, but the delay in receiving them contributed to the deficiency. The resident had repeatedly requested the appropriate utensil, and it was noted on his meal ticket, yet the staff often failed to provide it. This lack of consistent provision of adaptive equipment led to the resident's dissatisfaction and difficulty during meals.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had access to their call lights, which are essential for communication and requesting assistance. This deficiency was observed in two residents. Resident #4, who was admitted with diagnoses including Hemiplegia following Cerebral Infarction and Cerebellar Stroke Syndrome, was found in her room with the call light placed on a nightstand behind her, out of reach. Despite needing assistance with incontinence care, she was unable to reach the call light. A family member and the facility Ombudsman had previously expressed concerns about the resident's inability to access the call light, which was confirmed by a Certified Nurse Aide (CNA) during an interview. Similarly, Resident #5, who has been diagnosed with Major Depressive Disorder and Osteoarthritis, was observed sitting in a wheelchair with the call light hung over a wall-mounted light fixture, making it inaccessible. The resident confirmed the inability to reach the call light. The Director of Nurses acknowledged the importance of call light accessibility and stated it was the staff's responsibility to ensure call lights were within reach. The facility Administrator expressed surprise at the situation and confirmed that staff were expected to make rounds to check call light placement, although there was no specific policy in place regarding call light accessibility.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in their care. For Resident #5, the care plan identified the need to keep the call light within reach to assist with urinary incontinence and prevent falls due to right lower leg pain and a history of falls. However, an observation revealed that the call light was placed out of reach, hanging over a wall-mounted light fixture on the opposite side of the room. This oversight prevented the resident from calling for assistance, as required by the care plan. Similarly, Resident #4's care plan included measures to prevent urinary tract infections and falls, such as keeping the call light within reach and ensuring the bed was in the lowest position. Observations and interviews revealed that the call light was out of reach, and the resident was unable to call for assistance with incontinence care. Additionally, after providing care, CNAs left the resident's bed elevated, contrary to the care plan's instructions. Interviews with staff, including the DON and the Administrator, confirmed the importance of adhering to care plans to meet residents' needs, highlighting the facility's failure to do so in these instances.
Inadequate Incontinence Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident who was always incontinent of bowel and bladder, as documented in the 5 Day Minimum Data Set. On the day of observation, the resident was left without incontinence care from 10:30 AM until 1:35 PM, despite the facility's policy requiring care every two hours and as needed. During the care provided at 1:40 PM, a CNA used improper techniques by wiping back to front multiple times with the same side of a disposable cleansing cloth, which contradicts the facility's policy of wiping front to back with a clean area of the cloth for each stroke to prevent urinary tract infections. Interviews with the CNAs and the Director of Nursing confirmed that the facility provided in-service training on proper incontinence care procedures, which were not followed in this instance. The documentation entered into the facility's system did not accurately reflect the timing of care provided, as it showed only one episode of care before 11:00 AM, despite the resident being observed without care for several hours. The facility's administrator confirmed the expectation for CNAs to adhere to the proper procedures to prevent infections.
Latest citations in Mississippi
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
The facility failed to protect resident narcotic medications from misappropriation when an LPN handed over a medication cart’s narcotic keys to an RN without performing required narcotic counts before and after the transfer, and the cart was later found unlocked in the nurses’ station. During the subsequent shift change count, staff discovered multiple missing doses of oxycodone-acetaminophen and hydrocodone-acetaminophen prescribed PRN for pain to four residents with conditions including dementia, COPD, dysphagia, and diabetic neuropathy. Review of individual controlled drug logs showed corrected balances to account for the missing tablets, confirming that controlled substances were unaccounted for during the period of unsecured cart access and improper key control.
Two ambulatory residents with dementia, severe cognitive deficits, and known wandering behavior, each wearing a wander guard bracelet, were able to exit through a unit door when a visitor held it open, despite the door alarm sounding and prior observations that they frequently walked together and approached doors. An LPN responded to the alarm and, along with other staff, initiated a search when the residents could not be found on the unit; staff ultimately located the residents across a four-lane highway and returned them to the building without injury. The incident occurred despite facility policies requiring use of a security system for residents unable to protect themselves from harm by wandering, and staff and leadership acknowledged that the residents had a history of walking the halls together and going to doors, and that increased monitoring and restricting visitor access to door codes could have prevented the elopement.
A cognitively impaired resident with dementia, agitation, and a history of wandering was previously assessed by the IDT as not being at risk for elopement and did not have elopement precautions in place. On one occasion, a visitor exited through the front door without realizing the resident followed outside, and staff later discovered the resident alone on the front porch after being missing for several minutes. An LPN and CNA participated in locating and returning the resident, and the incident revealed that supervision and elopement risk assessment were insufficient for this resident.
A resident with Type 2 DM and moderately impaired cognition had two unstageable heel DTIs documented on the MDS and physician orders for treatment to both heels, but the comprehensive care plan did not include any problem, goals, or interventions related to these pressure injuries. LPNs responsible for MDS and care plan completion acknowledged the omission and stated that although they periodically audit by comparing orders to the care plan, this situation was missed. The DON reported she expected the wound care nurse to update the care plan with new wound treatment orders, while an RN stated she could update interventions but had not been trained to create a new focused care plan and was unaware it was her responsibility to add the DTI treatment orders to the care plan.
A controlled substance prescribed for a cognitively intact resident with a left femur fracture was delivered and signed for by an LPN but was not entered on the narcotic accountability record or narcotic box package count and was later found to be missing. One LPN reported receiving the blister pack of thirty Hydrocodone/Acetaminophen 10-325 mg tablets from another LPN, placing it on the nurses’ station, and leaving the area, while both LPNs stated they were in the medication room as the medication remained unattended. The DON and Administrator confirmed that staff failed to secure the controlled medication as required by facility policy and that the missing tablets could not be located.
Surveyors found that staff failed to properly secure and store medications for two residents. For one resident, an LPN received a delivery of Hydrocodone-Acetaminophen, passed it to another LPN, and the controlled medication was left unattended at the nurses’ station instead of being immediately locked and entered into the narcotic count, after which it could not be located. For another resident, two bottles of Lorazepam oral concentrate, documented on the narcotic record and labeled to be protected from light and refrigerated, were observed stored in a locked medication cart rather than in the designated medication refrigerator, even though staff acknowledged knowing the manufacturer’s refrigeration requirement.
A resident with hemiplegia and hemiparesis following cerebral infarction was transferred by facility van to a psychiatric hospital for evaluation and was later determined by the facility to be discharged due to aggressive behavior and threats, with staff stating they could not meet the resident’s needs. The Administrator and Social Services Director communicated with the psychiatric facility and the resident’s family about finding alternative placement and informed the family the resident would not be allowed to return, but no formal involuntary discharge notice or written appeal rights were provided, and no physician discharge order was documented, contrary to facility policies requiring a completed transfer form and written notice of transfer/discharge with appeal information.
The facility did not adequately investigate, address, or resolve repeated grievances about food quality and temperature raised through Resident Council meetings. Over several months, residents reported that weekend meals were bad, food was consistently cold, beverages lacked sufficient ice, and breakfast items were hard or unpalatable. While limited steps such as using temperature-holding containers, sending trays out faster, and in-servicing dietary staff were noted, there was no documented monitoring, follow-up, or evaluation of effectiveness. Cognitively intact residents continued to report cold, poor-tasting food, and staff, including the Dietary Manager and Social Services, acknowledged awareness of the complaints without evidence of thorough follow-up or resolution.
Failure to Implement Care Plan for Ankle Splint and ROM Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for contracture management and splinting to prevent decline in range of motion for one resident. The facility’s policy on prevention of decline in range of motion required that, based on the comprehensive assessment, the facility provide interventions, exercises, and/or therapy to maintain or improve ROM. The resident’s care plan, initiated on 8/1/25, identified an ADL self-care performance deficit related to stroke, hemiplegia, and immobility, placing the resident at risk for functional decline. The care plan interventions directed staff to apply a splint to the right ankle after breakfast, provide passive stretch to the right ankle after applying the splint, remove the splint at lunchtime, reapply the splint after supper with passive stretch, and remove the splint at bedtime. On observation, the resident’s ankle splint was not in use and was found lying in a chair in the resident’s room, and the resident was unsure when the splint was last applied. The PTA reported that the resident had developed foot drop and that the ankle splint could no longer be placed without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON stated that the care plan was used to inform staff how to care for the resident and verified that staff failed to follow the care plan when they did not apply the ankle splint. Record review showed the resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an MDS assessment indicated a BIMS score of 5, reflecting cognitive impairment at the time of the deficiency.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Failure to Secure Narcotic Medications and Maintain Key Control
Penalty
Summary
The deficiency involves the facility’s failure to protect resident medications from misappropriation on one of four medication carts, resulting in missing controlled substances for four residents. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the resident’s consent. On a specific date, during the 7:00 PM shift change narcotic count, staff identified that multiple doses of Percocet and Norco (hydrocodone-acetaminophen) were missing from the narcotic box on a single medication cart. Prior to this discovery, the assigned LPN had confirmed that the narcotic count was correct earlier in the day. The events leading to the deficiency included the LPN giving her medication cart narcotic keys to an RN while she left the area to perform a urine specimen collection. The LPN did not complete a narcotic count before or after transferring the keys, which was not in accordance with facility expectations for key control and chain of custody. When the LPN returned, she observed the medication cart in the nurses’ station and unlocked. The RN later confirmed that she had moved the cart into the nurses’ station but denied administering any medications during the time she had possession of the keys. During the subsequent 7:00 PM narcotic count, discrepancies were identified, and a search of the cart and nurses’ station did not locate the missing medications. Record review showed that four residents’ controlled medication logs required corrections to reflect missing tablets. One resident with dementia had an order for oxycodone-acetaminophen 5-325 mg every 12 hours as needed for pain; the narcotic log initially showed a remaining balance of 20 tablets after a documented administration, but was later corrected to 16 tablets to account for four missing tablets. A second resident with COPD had an order for oxycodone-acetaminophen 10-325 mg every eight hours as needed; the log was corrected from a remaining balance of five tablets to four, indicating one missing tablet. A third resident with dysphagia had an order for hydrocodone-acetaminophen 5-325 mg every 24 hours as needed; the log showed two tablets on hand after the resident returned from pass with no administrations documented, and was later corrected to zero, indicating two missing tablets. A fourth resident with type 2 diabetes mellitus with diabetic neuropathy had an order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed; the log was corrected from a remaining balance of eight tablets to seven, indicating one missing tablet. These discrepancies, combined with the unsecured cart and improper key transfer without counts, led to the determination that resident medications were not protected from misappropriation.
Failure to Prevent Elopement of Two Cognitively Impaired Wanderers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with known wandering and elopement risk. Both residents were ambulatory, frequently walked throughout the facility together, and were known to staff as wanderers. Each resident had a diagnosis of dementia with severe cognitive deficits documented on their MDS assessments, and both had Wander/elopement alarms (wander guard bracelets) in place and used daily. The facility’s elopement/wandering policy stated that residents who are incapable of adequately protecting themselves and unable to determine when they are at risk for harm by wandering out of the facility should be placed on the resident security system to ensure safety. On the day of the incident, video surveillance later reviewed by the Administrator showed that a visitor entered an exit door on the B Unit at approximately 6:20 PM. The two residents at risk for elopement approached the door, and the visitor held the door open, allowing them to walk out of the building. The residents were wearing wander guard bracelets, and when they exited, the door alarm sounded. A nurse responded immediately to the alarm, exited the facility, and went down the walkway but did not see the residents. Staff were then alerted that the residents were missing, and a facility-wide search was initiated. Staff interviews and the facility’s documentation confirmed that the residents had previously been observed walking together throughout the facility and approaching doors, including the exit door involved in the incident. The Administrator reported that review of the video showed the two residents had approached the same door together two or three times prior to the elopement event. Despite their known patterns of wandering, severe cognitive impairment, and prior door-approach behavior, the residents were able to exit the facility unnoticed and unsupervised when the visitor held the door open. Staff ultimately located the residents across a four-lane high-capacity highway approximately 528 feet from the exit door and returned them to the facility, where body audits and assessments documented no injuries and intermittent confusion. The State Agency determined that the facility’s failure to provide adequate supervision to prevent the elopement of these residents, who had exhibited exit-seeking behaviors, placed them and other residents at risk for wandering and elopement in a situation likely to cause serious injury, harm, impairment, or death and cited the facility at F689 with Immediate Jeopardy and Substandard Quality of Care. The residents’ medical records and elopement reports documented that both were confused, had impaired memory, and were identified as wanderers. One resident had a BIMS score of 3 and the other a BIMS score of 0, both indicating severe cognitive deficits. Progress notes and elopement reports recorded that staff were notified when the residents were not on the unit and could not be located, that all staff were engaged in searching, and that the residents were ultimately found outside and assisted back into the building. Interviews with CNAs and an LPN described hearing a Code W called, running outside, and seeing the residents across the street after they had crossed the four-lane highway. The DON acknowledged that the residents were always walking in the facility, often together, and that they had wandered to doors and looked out, and agreed that increased monitoring and not allowing visitors to have door codes could have prevented the residents from leaving the building.
Removal Plan
- Conducted a facility search.
- Notified police of missing residents.
- Director of Nursing interviewed staff and residents.
- Notified the Medical Director and residents’ families.
- Administrator and Director of Nursing checked the wander guard system and facility doors to ensure proper functioning.
- Returned Resident #1 and Resident #2 to the facility.
- Completed an incident report.
- Completed an emergency Quality Assurance meeting.
- Initiated in-service training for all staff on the elopement policy, including a quiz to validate comprehension, and required staff (including contract staff) to complete the in-service before working their next scheduled shift, with Administrator monitoring compliance.
- Responded immediately to the door alarm by sending staff outside to locate residents and notifying additional staff to assist with the search.
- Reviewed video surveillance and confirmed a visitor held the door open allowing residents to exit.
- Held an emergency Quality Assurance meeting with the Medical Director, Director of Nursing, Administrator, Regional Director, involved staff, and Infection Preventionist.
- Changed the main entry door code.
- Verified entrance door signage was in place instructing not to allow residents to exit unaccompanied.
- Identified residents at risk for elopement and ensured elopement bracelets/transmitters were functional and doors were locking appropriately.
- Reviewed care plans for residents at risk for elopement.
- Completed body audits on Resident #1 and Resident #2.
- Conducted audits verifying resident location, elopement risk, and wander guard bracelet function.
- Medical Records updated care profiles of residents at risk for wandering.
- Assistant Administrator began audits of all doors for function and security.
- Provided in-services on elopement policy and procedure, Resident Rights, and incident and accident reporting.
- Conducted elopement drills on each shift.
- Implemented monitoring systems to sustain compliance.
- Director of Nursing to monitor wander guard system checks three times weekly for four weeks or until substantial compliance is attained.
- Director of Nursing to monitor resident behavior for elopement attempts via incident reports, observations, and communications weekly for four weeks or until substantial compliance is attained.
- Quality Assurance Committee to meet for four weeks to review compliance with the plan of action, then continue routine Quality Assurance monitoring if no further concerns are noted.
- Administrator to hold follow-up Quality Assurance meetings monthly for two months then quarterly thereafter to ensure sustained compliance.
- Updated entry screening kiosk to include an additional reminder and attestation to ensure resident safety, requiring visitors to agree that no resident comes in or out with them and triggering a staff alert if the visitor refuses.
- Administration spoke directly with the visitor to confirm visitor policies and procedures.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the building unattended. The resident had diagnoses including dementia with agitation and a BIMS score of three, indicating severe cognitive impairment. The resident had been readmitted from a geriatric psychiatric hospitalization and was known by the DON to have a history of wandering. Despite this, the interdisciplinary team had previously determined that the resident was not at risk for elopement, and no elopement interventions such as a wander guard were in place at the time of the incident. On the day of the event, a visitor observed the resident standing near the front door and exited the facility without realizing the resident followed him outside. Staff later became aware that the resident was missing, and an LPN assisted in locating the resident. A CNA ultimately found the resident outside on the front porch and returned the resident to the facility, with the investigation determining the resident had been outside unattended for approximately five minutes. Staff interviews confirmed that the resident ambulated in the halls and had not previously attempted to exit the building, and that the resident was only reassessed and provided with a wander guard after the incident.
Failure to Care Plan for Pressure Injuries and Treatment Orders
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with pressure injuries. The facility’s undated Care Plan Policy and Procedure stated that each resident’s care plan would remain current and inform staff of needs, strengths, goals, and approaches, and that a comprehensive person-centered care plan would be completed as needed. Record review showed that the resident was admitted with Type 2 Diabetes Mellitus with ketoacidosis without coma and, per the Discharge MDS with an ARD of 1/19/26, had a BIMS score of 12 indicating moderately impaired cognition. Section M of the MDS documented two unstageable pressure injuries presenting as deep tissue injuries (DTIs). Physician orders dated 12/10/25 directed treatment to right and left DTI pressure ulcers. Despite these documented DTIs and treatment orders, review of the resident’s comprehensive care plan revealed no care plan addressing the DTIs on the left and right heels, which was inconsistent with the physician orders. During interviews, two LPNs responsible for MDS and care plan completion confirmed that the care plan did not include the DTIs and stated that care plans are developed based on the MDS and physician orders, and that audits comparing orders to care plans are done periodically but this had been missed. The DON stated her expectation that the wound care nurse update the care plan with new wound care treatment orders. An RN reported she could update care plan interventions but had not been trained to develop a new focused care plan and had not added the physician’s DTI treatment orders to the care plan, and she was not aware it was her responsibility to do so.
Unsecured Controlled Medication Left Unattended and Lost
Penalty
Summary
The facility failed to prevent misappropriation of resident property when a controlled substance prescribed for a resident was left unattended and subsequently went missing. Facility policies on abuse and neglect defined misappropriation of resident property to include missing prescription medications or diversion of resident medications, including controlled substances, and the Medication-Controlled Substances policy required that only authorized licensed nursing and pharmacy personnel have access to controlled medications, that all controlled substances be stored in a locked cabinet or compartment, and that accurate accountability of all controlled drugs be maintained. Despite these policies, a pharmacy courier delivered thirty Hydrocodone/Acetaminophen 10-325 mg tablets for a resident with a left femur fracture, and the medication was signed for by an LPN but was not signed onto the narcotic accountability record, was not documented on the narcotic box package count, and could not be located. The resident, who was cognitively intact with a BIMS score of 15 and had a physician’s order for Hydrocodone/Acetaminophen, was later informed that the tablets delivered had been lost. Interviews revealed that one LPN received the blister pack of thirty Hydrocodone/Acetaminophen tablets from another LPN and placed it on the nurses’ station before leaving the area, leaving the controlled medication unattended. Both LPNs reported being in the medication room while the medication remained unattended at the nurses’ station. The DON reported being notified that the medication was missing and that an investigation confirmed the medication could not be located and had been left unattended, and the Administrator confirmed staff failed to ensure controlled medications were secured and accessible only to authorized personnel and that the facility was unable to determine the location of the missing medication.
Failure to Secure Controlled Drugs and Follow Refrigerated Storage Requirements
Penalty
Summary
The deficiency involves the facility’s failure to store and secure medications, including controlled substances, in accordance with professional standards and manufacturer instructions. For Resident #1, who was admitted with a left femur fracture and was cognitively intact with a BIMS score of 15, the physician ordered Hydrocodone-Acetaminophen 10-325 mg tablets. A facility investigation documented that a pharmacy courier delivered 30 tablets of this controlled medication, which were received and signed for by an LPN but were never documented in the narcotic count system and were later unable to be located. One LPN reported that after receiving the Hydrocodone-Acetaminophen from another LPN, she left the medication unattended at the nurses’ station while she completed other tasks instead of immediately securing it in the locked medication cart. The LPN who initially received the medication from the courier confirmed that the controlled medication had not been immediately secured in the locked cart following delivery. For Resident #3, who was admitted with heart disease and had a BIMS score of 10 indicating moderately impaired cognition, the physician ordered Lorazepam (Ativan) oral concentrate. The narcotic record showed that two containers of Lorazepam were signed into the narcotic record on the date of admission. Manufacturer prescribing information for the Lorazepam oral concentrate specified that it must be protected from light and stored refrigerated at 36–46°F. During a controlled drug count, surveyors observed that two bottles of Lorazepam oral concentrate for this resident were stored in the locked medication cart rather than in a refrigerator, despite the label instructions requiring refrigeration. One LPN confirmed the manufacturer’s storage instructions on the label but was unsure why the medication had not been refrigerated, and another LPN acknowledged awareness that the medication required refrigeration but confirmed it had been stored in the medication cart instead of the designated medication refrigerator.
Failure to Provide Required Involuntary Discharge Notice and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of an involuntary discharge, including appeal rights, and to obtain a physician’s discharge order before refusing readmission of a resident following a hospital transfer. Facility policy titled “Transfer Form” stated that it is the policy of the facility to provide a completed and accurate transfer form to residents transferred or discharged from the facility, and the policy titled “Appealing a Transfer or Discharge Notice” stated that residents have the right to appeal transfer or discharge notices and, upon notice of transfer or discharge, will be provided with a statement of their right to appeal. Record review showed that the resident, admitted with hemiplegia and hemiparesis following cerebral infarction, left the facility by facility van to be admitted to a psychiatric hospital for evaluation. Progress notes dated several days after the transfer documented that the resident had been discharged from the facility due to aggressive behavior and that, per conversation with the psychiatric hospital, the Administrator and Social Services Director would assist in finding alternative placement and home health if needed. Documentation further indicated that, due to threats made, the facility stated it was unable to meet the resident’s needs and communicated with the resident’s family that the resident would not be allowed to return. During interview, the Administrator confirmed that neither the resident nor the family was provided a formal involuntary discharge notice or information on appeal rights and that no physician order for discharge could be located, acknowledging that the formal notice, appeal rights, and physician order should have been obtained prior to discharge.
Failure to Investigate and Resolve Ongoing Food-Related Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced through the Resident Council regarding food quality and temperature were thoroughly investigated, addressed, and resolved. Resident Council minutes over multiple months documented repeated complaints that weekend food was "bad," tasted sweet, and that food was cold by the time it reached residents. Additional concerns included insufficient ice in water and tea, hard breakfast biscuits and toast, and cold grits. Although the facility’s grievance policy stated that residents and families could voice grievances without reprisal and that the facility would make prompt efforts to resolve grievances, there was no documentation that the initial complaint about weekend food quality was addressed, and subsequent complaints continued without evidence of thorough investigation or resolution. Resident Council Department Response Forms showed limited actions, such as placing food in containers to maintain temperature, conducting an in‑service for dietary staff, sending food out faster, and instructing staff to pass trays promptly, but there was no documentation of monitoring, follow‑up, or evaluation of whether these measures were effective. Residents interviewed, all cognitively intact per their MDS BIMS scores, consistently reported that the food remained cold and did not taste good, with one resident noting that staff would reheat food only if requested. The Dietary Manager acknowledged awareness of the complaints and stated he had spoken with weekend staff and made changes like replacing tray carts and providing guidance on food preparation, but confirmed there was no documentation of ongoing monitoring or additional interventions. Social Services and the Administrator both acknowledged awareness of the complaints and that additional follow‑up and resolution efforts should have occurred, yet no evidence of such follow‑up was present in the records.
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